Epidural and spinal anaesthesia to relieve pain when giving birth

If you would like more information
If you have any questions about epidural/spinal anaesthesia, you can always talk to a midwife at the Maternity
Ward. The midwife or gynaecologist can also help you
contact an anaesthetist at the hospital where you are
going to give birth.
Epidural and spinal
anaesthesia to relieve
pain when giving birth
Anaesthesia Clinic
at Växjö Central Hospital
www.regionkronoberg.se
Issue 1, December 2014
Photos: Page 10, Jan-Michael
Breider, other photos Hans
Runesson.
You can order this brochure on audio CD,
in braille or in easy-to-read Swedish.
Contact the Information Department via the
switchboard on +46 (0)470 58 85 00.
Nerves
General
Epidural/spinal anaesthesia is the most effective
pain relief you can receive when giving birth. It is
effective without making you unconscious.
The difference between epidural and spinal
anaesthesia is the depth at which the anaesthetic is
injected into your back.
It is very rare to suffer any serious or long-term effects on your nerves, such as
pain, loss of sensation or paralysis from the epidural/spinal anaesthesia itself.
The risk in Sweden is approximately one in 200,000.
However, after the birth it is quite common for your nerves to have been affected
by the baby’s head pressing on the nerve endings that run along the inside of
the pelvic bone; this has nothing to do with the epidural/spinal anaesthesia.
This pain normally goes away by itself.
Infection
Preparations
Before giving birth, you normally talk to a midwife
to decide what kind of pain relief you want. You
should not have this kind of anaesthesia if you have
certain diseases that affect the nervous system, an
infection in your blood, or if you bleed more easily
or longer than normal.
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If you suffer from fever, headache or back pain up to three weeks after the
epidural/spinal anaesthesia, this could signal an infection. This can sometimes
be serious, so you should contact a doctor.
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Your baby’s heart sounds
As with some other kinds of pain relief, the heart rate of your unborn baby
can temporarily change as a result of the epidural/spinal anaesthesia. This does
not mean that the baby is unwell. It is more likely due to the rapid drop in the
amount of stress hormones and normally returns to normal by itself.
Overdose
Although this is very rare, if the drug used for low-dose epidural anaesthesia is
injected into the spinal fluid or into a blood vessel by mistake, there is a risk of
an overdose. If this happens, you may suffer a sudden drop in blood pressure,
drowsiness, temporary muscle paralysis and difficulty breathing. This is usually
harmless and returns to normal by itself. If your blood pressure is low, you may
need to have drugs to raise your blood pressure and some additional fluid in
your drip.
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Why are you given epidural/spinal anaesthesia?
Pain relief when giving birth
Although pain from giving birth differs from woman to woman, most normally
want to have some kind of pain relief when they are having a baby. You talk
with your midwife to decide which kind of pain relief is best for you.
Epidural/spinal anaesthesia is the best method for relieving pain during labour
and is the method that has been studied the most. It is also the most complicated
method. Although it is safe, there are some disadvantages and risks, just like all
pain relief.
Blocks nerves that transmit pain
This method involves injecting a local anaesthetic that blocks the nerves that
transmit pain from the womb and the pelvic floor. It is often mistakenly called
spinal cord anaesthesia, but it is not the spinal cord that is being anaesthetised,
but the nerves that go from it. It prevents the pain signals from reaching the
brain.
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The difference between epidural and spinal
anaesthesia:
• Epidural anaesthesia, EDA, is when the anaesthetic is injected into a narrow
cavity called the epidural space, just outside the spinal fluid. A tube is normally
used, called an epidural catheter, which remains inserted, enabling us to inject
more anaesthetic if needed. You feel the effect of the pain relief after 5-15
minutes.
• Spinal anaesthesia, is when the anaesthetic is injected directly into the fluid
in the spinal canal with a needle. You quickly feel the effect of the pain relief.
You do not lose consciousness
You do not fall asleep or lose consciousness in any other way from epidural/
spinal anaesthesia. It stops you from feeling drowsy and most women can stand
up and walk around without any problems.
Epidural/spinal anaesthesia is the most effective pain relief. The anaesthetic
means that you can have a drip to stimulate labour. If you do not have the
anaesthetic, the drip can cause you pain as the labour becomes more intense.
Sometimes the effect of the anaesthesia is not strong enough. The dose of the
anaesthetic or the position of the tube may need to be changed and sometimes
the anaesthetist may have to repeat the whole procedure.
Risks and unusual complications
There are risks involved with any kind of anaesthesia. Although epidural/spinal
anaesthesia is considered to be a very safe form of anaesthesia, there can be
complications in individual cases. These problems can range from mild pain to
very rare, but more serious complications.
Headaches
There is a chance that the epidural needle may pierce the spinal meninges by
accident, although this is rare, affecting one or two people in a hundred. If this
happens, you may suffer from a special and severe kind of headache which gets
worse if you stand or sit up, but which is relieved or disappears completely when
you lie down. As well as headaches, you may sometimes suffer from blurred
vision or impaired hearing. This kind of headache normally comes on 12-36
hours after you had the epidural anaesthesia. If the headache does not go away,
even if you drink a lot of water and take pain relief tablets, we will normally
treat you with a ‘blood patch’. This involves having a small amount of your own
blood injected into the epidural space to seal the hole in the spinal meninges.
This normally relieves the headache quickly, but sometimes the treatment needs
to be repeated. This treatment can only be given by an anaesthetist.
Drop in blood pressure
Although your blood pressure may drop, the risk is not very high if you have
been given a low dose. However, if this does happen, a drip or medicine to raise
your blood pressure will quickly make you feel better.
Fever
If you have epidural anaesthesia over a period of a few hours, you may suffer a
slight fever; it is unclear why this happens.
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What does the anaesthetic do?
When the anaesthetic starts to work, it will gradually reduce your labour pains.
The contractions will be shorter and less painful. When the anaesthetic is at
its full effect, you will still feel your contractions, but they will feel more like a
squeeze or a slight pain. You may sometimes feel heat in the lower part of your
body and your skin can feel slightly numb to the touch.
After the birth
Epidural/spinal anaesthesia does not increase the risk of back problems.
However, you may feel local tenderness in your back and sometimes a bruise
where the needle was injected. The bruise disappears and the tenderness passes
by itself, often within a few days.
Good with pre-eclampsia, for example
If you are in a lot of pain, the stress hormones adrenaline and noradrenaline
increase in your blood. Your blood pressure rises and the blood flow through
your placenta is reduced. Epidural/spinal anaesthesia can often lower the level
of these hormones in your blood, which has a positive effect on both your blood
pressure and the blood flow through your placenta. This is particularly important
if you suffer from pre-eclampsia, as your blood pressure is higher and the blood
flow through your placenta is reduced.
It may also be a good idea to have epidural/spinal anaesthesia if you suffer from
a serious heart or lung disease, as the anaesthesia reduces the stress on your body.
The same tube can also be used for emergency
caesareans
If a tube has already been inserted for epidural anaesthesia, we can sometimes
use the same tube if you need to have an emergency caesarean. This means that
we do not have to give you general anaesthesia, which is particularly good if
you suffer from pre-eclampsia or are severely overweight, when the risks from
anaesthesia are higher.
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You may also itch and find it difficult to urinate
Although severe complications are very rare, you may suffer minor side effects.
Around half of everyone who has epidural/spinal anaesthetic containing a
morphine-like substance suffers itching, but this itching is normally so mild
that you do not need any special treatment.
Most women do not have any problems urinating, but it can be difficult for
some. The midwife regularly checks your bladder during labour to make sure it
does not get too full.
Some women feel heaviness in their legs or are
slightly shaky
Approximately one out of ten women can feel heaviness in their legs or have
problems standing or walking. This risk increases the more local anaesthetic
you receive. This is harmless and the effect normally disappears within one or
two hours.
A short time after you have had the spinal/epidural anaesthetic, you may start
to shake slightly, like when you shiver. This is completely harmless and goes
away by itself.
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A plastic tube called an epidural catheter is inserted. Sometimes you may feel
an uncomfortable tingling, shock-like sensation in your side, your hip or one
of your legs if the tube touches a nerve root. This only lasts for a short while
and is harmless.
The needle is then removed and the tube is attached securely onto your back
with tape. The anaesthetist administers the first dose of local anaesthetic
combined with a morphine-like substance. It takes 5-15 minutes to feel the
effect of the pain relief. You will feel the full effect after 20-30 minutes. The
epidural anaesthetic can be topped up afterwards using a pump as and when
necessary. Your midwife checks your blood pressure a few times to make sure
that you have not suffered from a drop in blood pressure.
Spinal anaesthesia
The technique used is similar to epidural anaesthesia, but it is slightly easier.
Instead of a plastic tube, a thin needle is inserted through the spinal meninges
and the anaesthetic is injected directly into the fluid in your spinal canal.
Spinal anaesthesia is primarily used if you have given birth before and you are
coming to the end of a quick labour that is expected to finish within two hours.
The effect of the pain relief is quicker and is normally better than epidural
anaesthesia when you are pushing the baby out, but you may still feel a pressing
sensation on your genital area and against your rectum. The disadvantage is that
you will only feel the effect for a maximum of two hours, as you cannot top up
the anaesthetic afterwards.
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Labour can take longer
Sometimes the labour can take longer and your bearing-down reflex can be
weakened if you are given epidural/spinal anaesthesia. Researchers still do not
know how much this affects the bearing-down reflex, but it is probably not very
much with the weak mixtures of drugs that are used nowadays. If your labour
lasts for a long time, we can give you a drip with drugs to stimulate labour and
if it is difficult to bear down, we can also use a suction cup to help get your
baby out. Although it is more common to need a suction cup if you have had
epidural/spinal anaesthesia, you are still much more likely to have a completely
normal birth.
Epidural/spinal anaesthesia does not increase the risk of needing a caesarean
section.
It is important to remain still when the needle is
being inserted
The anaesthetist first washes your back with alcohol and injects a shallow local
anaesthetic into your skin. This may smart or burn for a short while.
After this, the epidural needle is inserted between two vertebrae in your lumbar
region. Although you might find it difficult to remain still when you are in
labour, it is important to be completely still to make sure that we can insert the
needle correctly into the epidural space. The epidural space is a small cavity just
outside the spinal canal and the hard spinal meninges.
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When should you not have epidural/spinal
anaesthesia?
Epidural/spinal anaesthesia is not always suitable as a form of anaesthesia. It
may be unsuitable, for example, if you:
•bleed more easily or longer than normal
•are on medication that affects the clotting ability of your blood
•have an infection in your skin where the needle will be injected
•have an infection in the blood, called sepsis
•have certain diseases that affect the nervous system
•have a disease that increases the pressure in the spinal fluid
•have certain kinds of spinal diseases or deformities of the spine
If you have a disease or are taking drugs that prevent us from administering
epidural/spinal anaesthesia, it is a good idea for you to meet an anaesthetist to
discuss your choice of pain relief method well in advance of the birth.
If you have a tattoo at the base of your spine, this is not normally a problem as
the anaesthetist can normally insert the needle to the side of the tattoo.
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The process
If you decide to have epidural/spinal anaesthesia after talking to your midwife
or obstetrician, we call an anaesthetist for you. In Växjö there is an anaesthetist
on site throughout the day and you rarely have to wait more than 30 minutes
during the day or one hour in the evening and at night.
It does not normally take long to have epidural/spinal anaesthesia, but if you
have previously had a back operation or a curved spine, scoliosis, it may take
longer and the doctor might not be able to give you epidural/spinal anaesthesia.
Epidural anaesthesia
You can have epidural anaesthesia at any time during the birth, but we normally
give it to you when labour has started and the cervix is open three to four
centimetres. Pain relief normally works very well when the cervix is opening,
but it can be less effective in the final phase when it is completely open.
Anaesthetic while you are on your side or
slouched on the bed
To make the space between the vertebrae as large as possible, you can lie on
your side in the foetal position with your knees drawn up and your chin against
your chest. Or you can sit slouched on the edge of the bed with your back bent.
If you are going to lie on your side when the epidural/spinal anaesthetic is
given, you need to try to pull your knees up as far as you can and arch your back
like a cat.
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